Bella Terra Lagrange
Inspection history, citations, penalties and survey trends for this long-term care facility in La Grange, Illinois.
- Location
- 4735 Willow Springs Road, La Grange, Illinois 60525
- CMS Provider Number
- 145737
- Inspections on file
- 25
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bella Terra Lagrange during CMS and state inspections, most recent first.
The facility failed to offer the COVID-19 vaccine to staff and did not document their vaccination status. The LPN/Infection Preventionist admitted there was no documentation showing the vaccine was offered. Staff were informed they could get vaccinated at clinics or pharmacies, but the facility did not actively offer it. The facility's policy required compliance with CMS, CDC, and IDPH guidance, but there was no documentation of staff education or vaccination status.
The facility failed to conduct and document required care plan meetings, and did not invite residents to participate in their care planning. Four residents, including those who are cognitively intact, reported not being aware of or invited to care plan meetings. The facility lacked documentation for these meetings, contrary to its policy and federal regulations.
A facility failed to label an IV antibiotic bag for a resident receiving Ceftriaxone for a liver abscess. The IV bag lacked necessary information such as date, time, and flow rate. The morning nurse confirmed the oversight, and the ADON stated the labeling requirements. The facility did not have a policy for IV bag labeling.
The facility failed to ensure proper labeling and secure storage of medications, affecting multiple residents. Medication blisters were improperly taped, and an insulin pen lacked labeling. Residents had medications at their bedside without proper orders or secure storage, including creams, eye drops, and Tums. Facility policies on medication storage and labeling were not followed, as confirmed by the ADON.
The facility failed to implement proper infection control measures, affecting multiple residents. A nurse did not perform hand hygiene between assisting residents during meals. A CNA did not clean hands after providing incontinence care, and another CNA failed to wear a gown and change gloves while caring for a resident under Enhanced Barrier Precautions. Soiled linen was also left on the floor in a resident's room. These actions violated the facility's infection control policies.
A resident's colonoscopy and EGD were rescheduled because the facility failed to hold a blood thinner as per physician's orders. Despite instructions to withhold Eliquis two days before the procedure, it was administered, leading to the inability to perform the procedure due to lack of IV access. The resident had a history of colon cancer and other significant health issues.
A nurse was observed standing over two cognitively impaired residents while feeding them, contrary to the facility's practice of maintaining dignity by being at the same eye level. One resident required partial assistance, while the other was totally dependent on staff for eating. The facility lacked a specific Residents' Rights policy but referred to a state-provided book mandating dignity and respect.
The facility failed to provide adequate ADL assistance to residents, resulting in unaddressed hygiene needs. A resident reported not being washed since admission, leading to discomfort and an unwanted beard. A CNA was unaware of their assignment to this resident. Additionally, two residents were observed with long, unclean nails, despite needing substantial assistance with personal hygiene. The ADON confirmed that staff are expected to provide such care according to the facility's policy.
A resident with multiple diagnoses, including a traumatic subdural hemorrhage and type 2 diabetes, exhibited signs of infection and abnormal vital signs. Despite orders from the NP to send the resident to the ER via 911, the facility used a regular ambulance, delaying urgent care. The decision was made after consultation between the RN and Nursing Supervisor, despite the resident's critical condition.
A resident experienced sexual abuse by a kitchen aide who exchanged inappropriate messages and photos with her, and made unwanted physical contact. Despite the resident's discomfort and attempts to maintain a friendship, the aide continued his advances. The aide admitted to exchanging phone numbers and sending photos but denied physical contact, claiming ignorance of the facility's abuse policies.
The facility failed to conduct a timely background check for a Kitchen Aide hired nearly three years prior, only completing it after an allegation arose. The facility's abuse prevention policy requires background checks and fingerprinting within 10 days of hiring, which was not followed, potentially compromising resident safety.
The facility failed to maintain comfortable air temperatures in resident rooms, affecting several residents who reported discomfort due to heat. Despite attempts to address the issue, room temperatures remained above the facility's comfort level policy, with high humidity levels exacerbating the situation. Maintenance staff did not effectively monitor room temperatures, and a malfunctioning air conditioner pump contributed to the problem.
The facility failed to ensure that call lights were within reach for two residents, as observed on 4/23/24. Both residents were unable to access their call lights, contrary to their care plans and the facility's policy. Staff interviews confirmed that call lights should always be accessible.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to its staff and did not maintain proper documentation of the vaccination status of its staff members. During an interview, the LPN/Infection Preventionist (V3) admitted that there was no documentation available to show that the vaccine was offered to staff. The facility's policy had changed, and the COVID-19 vaccines were no longer provided for free. Staff were informed that they could obtain the vaccine from clinics or pharmacies that accepted their insurance, but the facility did not actively offer the vaccine to them. Additionally, there was no documentation available to confirm that staff were educated about the benefits and potential side effects of the COVID-19 vaccine, nor was there any record of staff accepting and receiving the vaccine. The facility's policy, dated 7/16/24, stated that it would comply with CMS, CDC, and IDPH guidance on COVID-19 vaccination. Although CMS had rescinded the mandatory COVID-19 vaccine requirement for staff and residents, the facility was expected to continue promoting and providing the vaccine whenever available and with individual consent. However, the facility's infection control binders lacked any documentation of staff education or vaccination status, indicating a failure to adhere to its own policy and regulatory expectations.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to conduct required care plan meetings and invite residents to participate in their care planning process. This deficiency was identified for four residents who were reviewed for care planning. Resident R32, who is cognitively intact, reported not knowing what a care plan meeting was and had never been invited to one. The facility was unable to provide any documentation of care plan meetings for R32 for the past year. Similarly, resident R69, also cognitively intact, stated he had never been invited to a care plan meeting despite being in the facility for over two years. The only care plan documentation available for R69 was dated several months prior, with limited attendees noted. Resident R79, who is cognitively intact, also reported not being invited to a care plan meeting, with documentation showing only family members and facility staff as attendees. Resident R20, with moderate cognitive impairment, had no documentation of care plan meetings in the past year. The Social Services Director acknowledged the lack of documentation and stated that residents should be invited to their care plan meetings to ensure their needs are met. The facility's policy requires care plans to be developed in conjunction with federal regulations, but this was not adhered to in these cases.
Failure to Label IV Antibiotic Bag
Penalty
Summary
The facility failed to ensure proper labeling of an IV antibiotic therapy bag for a resident, leading to a deficiency. During an initial tour, it was observed that a resident, who was lying in bed, had an empty IV bag of Ceftriaxone without any label indicating the date and time. The resident was receiving this antibiotic for an abscess in her liver. The morning nurse confirmed that the IV antibiotic was administered during the night shift but acknowledged that the bag should have been labeled with the date, time, flow rate, and room number. The Assistant Director of Nursing also stated that nurses are required to include the patient's name, medication details, start time, rate, and initial the bag. The facility was unable to provide an IV therapy policy that included the labeling of IV bags.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, affecting eight residents. During a review of the medication carts, it was observed that medication blisters for hydrocodone-acetaminophen, pregabalin, and lorazepam were taped closed instead of being wasted, as per facility policy. The LPNs involved were unsure of the correct procedures for handling these medications. Additionally, an insulin aspart flex pen was found without a label indicating the resident's name or the dates it was opened and should be used by, which is against the facility's policy. Several residents were found to have medications at their bedside without proper physician orders or secure storage. One resident had Nystatin cream and lubricant eye drops in her bedside drawer, with no physician order for the eye drops. Another resident had a bottle of Tums in her drawer, which was not ordered by a physician. Similarly, a resident had a cup of Tums on her bedside table, which she stated was left by the nurse for her to take at will, despite the physician's order specifying a different medication. The facility's policies on medication storage, labeling, and disposal were not adhered to, as evidenced by the presence of medications in residents' bathrooms and on bedside tables. This included hydrocortisone cream and zinc oxide ointment found in a resident's bathroom, and an Albuterol inhaler and fluticasone nasal spray on another resident's overbed table. The Assistant Director of Nursing confirmed that medications should be locked and secured, and not left in residents' personal spaces for safety and hygiene reasons.
Infection Control Deficiencies in Resident Care and Linen Handling
Penalty
Summary
The facility failed to implement proper infection control measures during resident care and handling of soiled linen, affecting six out of seven residents reviewed for infection control. During a lunch service, a nurse was observed wiping food off one resident's mouth and then feeding another resident without cleaning her hands in between, continuing this practice throughout the meal. The Assistant Director of Nursing later confirmed that hand hygiene should have been performed between assisting each resident. In another instance, a CNA provided incontinence care to a resident without performing hand hygiene after wiping the resident's buttocks, subsequently touching bed linens and bedrails with contaminated gloves. The CNA acknowledged the lapse in hand hygiene, and the Wound Nurse present also noted the failure to clean hands. Additionally, another CNA failed to wear a gown while providing care to a resident under Enhanced Barrier Precautions, used the same washcloth for different areas without folding it, and did not change gloves or perform hand hygiene before applying barrier cream and handling objects in the room. The facility's infection control policies, including Enhanced Barrier Precautions and Hand Hygiene, were not adhered to, as evidenced by staff not wearing gowns during high-contact care activities and leaving soiled linen on the floor in a resident's room. The Assistant Director of Nursing confirmed that soiled linen should not be left on the floor and should be bagged and sent to the laundry. These observations indicate a failure to follow established protocols to prevent the spread of infections within the facility.
Failure to Follow Physician's Orders for Procedure
Penalty
Summary
The facility failed to follow physician's orders for a resident scheduled for a colonoscopy and an EGD. The gastroenterology office had sent a procedure reminder form indicating that the resident's blood thinner, Eliquis, should be held two days prior to the procedure. However, the resident's Medication Administration Record showed that the blood thinner was administered on the day it was supposed to be held, leading to the procedure being rescheduled. The resident, who had a history of colon cancer and multiple other diagnoses including pulmonary embolism and heart failure, was unable to complete the colonoscopy due to the administration of the blood thinner and the inability to establish intravenous access. The facility's administrator acknowledged that the nurse did not follow the doctor's orders, which resulted in the failure to perform the scheduled procedure.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure residents were treated with dignity while providing care, as observed during a survey. A nurse was seen standing over two residents while feeding them their lunch, which is against the facility's practice of maintaining dignity by being at the same eye level as the residents. This practice is important for the residents' comfort and respect. Both residents involved had severely impaired cognition, with one requiring partial/moderate assistance for eating and the other being totally dependent on staff for eating. The facility lacked a specific Residents' Rights policy but referred to a state-provided Residents Rights book, which mandates treating residents with dignity and respect.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for residents who required help to maintain their cleanliness and comfort. One resident, who had been in the facility since March 21, 2025, reported not having been washed since admission, resulting in discomfort due to sweat and an unwanted full beard. The resident expressed that staff did not introduce themselves and felt like a burden when requesting assistance. A Certified Nursing Assistant (CNA) admitted to not knowing the resident was on their assignment and stated that care would only be provided if time allowed after assisting other residents. Additionally, two other residents were observed with long, jagged nails with a brown substance underneath, indicating a lack of personal hygiene care. One resident's electronic health record indicated a need for substantial assistance with personal hygiene, while the other resident was noted to have severely impaired cognition and was dependent on staff for hygiene care. The Assistant Director of Nursing acknowledged that staff are expected to provide ADL care, including nail trimming, as per the facility's General Care policy, which aims to meet the residents' needs.
Failure to Use 911 for Resident with Critical Condition
Penalty
Summary
The facility failed to send a resident to the hospital emergency department via 911 after a significant change in condition. The resident, who was admitted with multiple diagnoses including traumatic subdural hemorrhage, lumbar vertebrae fracture, type 2 diabetes, and cognitive communication deficit, exhibited abnormal vital signs and laboratory results indicating a potential infection. On December 30, 2024, the resident's blood work showed elevated white blood cell count, and by January 1, 2025, blood cultures revealed staphylococcus aureus, with the resident displaying low blood pressure, high heart rate, and fever. Despite these concerning signs, the resident was not transported to the hospital via 911 as recommended by the Nurse Practitioner (V6), who was informed of the resident's condition and ordered immediate transfer for further evaluation and treatment. Instead, the resident waited for a regular ambulance, delaying the transfer. The decision to use a regular ambulance was made after consultation between the Registered Nurse (V7) and the Nursing Supervisor, despite the resident's critical condition. The Primary Care Physician (V3) and the Nurse Practitioner both indicated that the resident's condition warranted an emergency response due to the risk of sepsis and the need for immediate medical intervention. The failure to use 911 for transport was a significant oversight, as the resident's vital signs and laboratory results clearly indicated a need for urgent care, which was not promptly addressed by the facility staff.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by the interactions between a resident and a kitchen aide. The resident, a cognitively intact Spanish, American Indian woman with paraplegia and other medical conditions, reported that the kitchen aide kissed her and touched her chest. The inappropriate relationship began when they exchanged phone numbers and communicated through the WhatsApp application, where the aide sent inappropriate messages and photos to the resident. The resident described feeling uncomfortable as the kitchen aide's messages became increasingly inappropriate, asking about her catheter and making sexual comments. Despite the resident's attempts to maintain a friendship, the aide continued to send suggestive messages and photos, and visited her room on two occasions, during which he made unwanted physical contact. The resident did not report the incidents until she feared being discharged from the facility. The kitchen aide admitted to exchanging phone numbers and sending photos but denied any physical contact. He claimed he was unaware of the facility's policies regarding abuse and relationships with residents, although he acknowledged that personal relationships with residents were inappropriate. The facility's abuse and neglect policy clearly states that any sexual behavior or relationship initiated by a staff member with a resident is considered sexual abuse unless there was a pre-existing relationship prior to admission.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a timely background check for a new hire, identified as V3, a Kitchen Aide. V3 was hired on February 20, 2022, but the Illinois State Police background check was not conducted until December 9, 2024, nearly three years later. Additionally, the Illinois Department of Public Health (IDPH) Health Care Worker Registry initially showed no record of V3, indicating that the necessary checks were not performed at the time of hire. This oversight was discovered when an allegation involving V3 arose, prompting the facility to review his file and realize the absence of the original background check and fingerprinting. The facility's abuse policy, dated July 12, 2024, mandates that background checks and fingerprinting be conducted within 10 days of hiring for non-licensed staff, in compliance with federal guidelines for abuse prevention. The policy outlines seven components of prevention and investigation, including screening potential employees for any history of abuse, neglect, or exploitation. However, the facility did not follow these procedures for V3, as evidenced by the delayed background check and fingerprinting, which were only completed after the allegation surfaced. This failure to comply with established protocols potentially compromised the safety and well-being of the 99 residents residing in the facility.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable air temperatures in resident rooms, affecting 9 out of 9 residents reviewed for a homelike environment. Residents and their families reported that the rooms were too hot and uncomfortable, with air conditioning units providing insufficient cooling. The facility's maintenance staff attempted to address the issue by replacing and flushing air conditioner unit water lines, but the problem persisted, particularly during a heat wave when outdoor temperatures reached as high as 97 degrees Fahrenheit. Observations and measurements taken by maintenance staff and a journeyman from a contract company revealed that room temperatures ranged from 76.6 to 79 degrees Fahrenheit, with humidity levels between 55% and 62%. These conditions were above the facility's policy comfort level of 68-75 degrees Fahrenheit. The facility's policy also required ambient temperatures to remain between 71 and 81 degrees Fahrenheit, but the high humidity and warm temperatures in resident rooms and common areas indicated a failure to adhere to these guidelines. The facility's maintenance staff did not begin taking resident room temperatures until the outdoor temperatures rose above 80 degrees, and only surface temperatures were initially measured using a laser thermometer. The facility's policy on extreme high temperatures required random temperature checks of resident rooms and common areas, but these checks were not conducted effectively. The main air conditioner chilled water pump on the second floor was not working and was only repaired after the issue was identified, contributing to the uncomfortable conditions experienced by residents.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were within their reach, affecting two of the four residents reviewed. On 4/23/24, Resident 3 was observed sitting in her wheelchair with her call light wrapped around the upper left side rail, making it unreachable. Similarly, Resident 4 was found sitting in her wheelchair with her call light placed behind her on the nightstand, also out of reach. Both residents confirmed their inability to reach their call lights when needed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), revealed that it is standard practice to keep call lights within residents' reach. The facility's administrator also confirmed that call lights should always be accessible to residents. The care plans for both residents indicated that their call lights should be kept within reach, and the facility's Call Light Policy supports this requirement. Despite these guidelines, the facility did not comply, leading to the observed deficiencies.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
